BUBREŽNE PROMJENE U VASKULITISU: PRIKAZ BOLESNIKA

Krešimir Galešić, Jadranka Morović-Vergles, Danica Ljubanović

Sažetak. U radu je prikazano petnaestero bolesnika s vaskulitisom i bubrežnim promjenama: u šestero bolesnika dijagnosticiran je mikroskopski poliangitis, u četvero Wegenerova granulomatoza, u dvoje mikroskopski poliangitis ograničen na bubrege, a u troje nodozni poliarteritis. U trinaestero bolesnika učinjena je biopsija bubrega, a nije u dvoje: u jedne bolesnice zbog uznapredovale bubrežne insuficijencije i smanjenih bubrega, a u drugog bolesnika jer je dijagnoza nodoznog poliarteritisa postavljena na osnovi drugih kliničkih i laboratorijskih nalaza. U jedanestero bolesnika biopsijom bubrega utvrđen je pauciimuni tip glomerulonefritisa. Zastupljenost polumjeseca u histološkim nalazima bila je 20–100%. Polumjeseci su bili celularni, odnosno fibrocelularni, rjeđe fibrozni. U četrnaestero bolesnika bubrežna insuficijencija (vrijednosti kreatinina 215–1224 µmol/L) bila je prisutna pri postavljanju dijagnoze, a samo je u jednog bolesnika koncentracija kreatinina u krvi tijekom dijagnostičkog postupka bila granična (115 µmol/L). Bolesnici s glomerulonefritisom liječeni su primjenom glukokortikoida i ciklofosfamida, a petero bolesnika s plućnim manifestacijama bolesti i/ili uznapredovalom bubrežnom insuficijencijom i plazmaferezom. Tijekom liječenja dijalizirano je osmero bolesnika. Godinu dana nakon početka liječenja kompletna ili parcijalna remisija postignuta je u devetero bolesnika, a petero bolesnika nastavilo je liječenje dijalizom zbog kronične bubrežne insuficijencije. Bolesnik s Wegenerovom granulomatozom i ulceroznim kolitisom koji je operiran zbog toksičnog megakolona umro je sedmoga postoperativnog dana zbog sepse.

Summary. Fifteen patients with vasculitis and renal manifestations have been analyzed. All patients had renal manifestation of vasculitis. Renal biopsy was performed in 13 patients: 6 patients had microscopic polyangiitis, 4 Wegener’s granulomatosis, 2 microscopic polyangiitis limited to the kidneys and 3 polyarteritis nodosa. Renal biopsy was not performed in 2 patients. One patient had renal insufficiency and small kidneys and one patient had polyarteritis nodosa. The diagnosis of the polyarteritis nodosa in this last patient was made because of other clinical and laboratory data. Pauci-immune type of glomerulonephritis was found in 11 patients. The crescents, usually cellular, fibrocellular and rarely fibrotic, were present in 20–100% glomeruli. Renal insufficiency at baseline was present in 14 patients (creatinine 215–1224 µmol/L). Only one patient had borderline renal function when the diagnosis of vasculitis was made (creatinine 115 µmol/L). All patients with glomerulonephritis were treated with glucocorticosteroids and cyclophosphamide. Five patients with pulmonary manifestations of disease or advanced renal failure also were treated with plasmapheresis. Eight patients were treated by hemodyalisis. The complete or partial remission in the first year of the follow-up was reached in 9 patients, and 5 patients were treated by chronic dialysis due to chronic renal failure. One patient with Wegener’s granulomatosis died after he developed toxic megacolon and postoperative sepsis.